Laserfiche WebLink
Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1 Generator ID Number F�' _ 2.Pae 1 of 3.Emergency Respense Phone 4.Manifest.Tracking Number <br /> WASTE MANIFEST � � 1 `�>:_ : 17483681 J J K <br /> 5.Generator's Name and Mailing Address vm� Generator's SiteAddress(if different than mailing address) <br /> IF <br /> a' <br /> Generator's Phone: t� <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> t;�EAt�tTL ti L�f+ ll t�h!fFxL II C <br /> CALGO0651W <br /> 7.Transporter 2 Company-Name U.S.EPA lD Number <br /> 8.Designated Facility Name and Site AL <br /> Address � �T U.S.EPA Ip Number <br /> TE-Ch6830 MARTIN RD <br /> tRY44DALE,CA 91 T06 USA <br /> Facility's Phone:. 626-812--l" <br /> 9a <br /> 812- <br /> ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 16.Containers 11.Tota€ 12,Unit 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity Vt.t.Nol. <br /> 1. <br /> N-ftGFRAI IAZARDOUS WASTE SOW(011:Y SCUD VPSTFJUSeD ON <br /> d 1v1ETAL 41L FLTERS) ....... <br /> ` I <br /> UJ <br /> r� McDIAj <br /> i <br /> 3, 717 MP99Y%QQU&A0S464XYdll <br /> t <br /> 4. <br /> 14.Special Handling.Instructigns d�ddi' I tion <br /> }i�kh-LE-9 "2.._..,�,...�METALFILTERS)982)PROM..E F (P. Ei !"fl.Tt l4S) <br /> 903)PROF(ef(URED ABSORIBENT)USED GLOVES AND�47t:3Cki.�3 TRU K# At y <br /> MUST IDENTFY CLEMTECH ENVIRONWIl ,.AS REGISTE T INFOR TR 800-636-A <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment,are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and labeledlplacarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations.If export shipmentand I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the.terms of the attached EPAAcknowledgment of Consent. � <br /> 1 certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a mall quantiity�gernerator)is true: <br /> Gerlerator's1OIferor's-P' tedirr ped game Signature M Da ear <br /> JAI— <br /> r 16.IntemabonalShlpmenis <br /> r ❑Impart to.U.S. ❑Export from U.S. Port of antrylexib _- <br /> Z Transporter signature(for exports only): pate(Raving U.S.: <br /> 17.TransporterAcknowledgment of Receipt of Materials; f f <br /> TransptediTyp d Name Sigriat�ire J� I Monti D rear <br /> 0- Ali <br /> Z Transporter 2 Printedrrypr d Name Signature Month Day Year <br /> r <br /> 18.Discrepancy <br /> laa.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejecfion ❑Full Rejection <br /> Manifest Reference Number. <br /> F 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> w Facility's Phone: <br /> w 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> a <br /> z <br /> 1:9,Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 0 �4 2. 3 4 <br /> 20.Designated Facility Owner at Operator:Certification of receipt of hazardous materials covered by the manifest except as.nowd in.Item 18a <br /> Sreriey-. r ay �1-1ef <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR <br />